The Sleep Cycle Running head: THE SLEEP CYCLE

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The Sleep Cycle: Normalcy, Insomnia, and its Relationship to !manda "a#er $ni%ersity o& E%ans%ille, Indiana epression

The Sleep Cycle Personal Rele%ance Pre&ace (y educational goal is to pursue a graduate degree either in the &ield o& clinical social )or# or clinical psychology* !s a pro&essional, I hope to )or# in a clinical setting* In either o& the pro&essions that I plan to pursue, I )ill treat a %ariety o& clients )ith pro+lems ranging &rom children e,periencing ad-ustment pro+lems in school to older adults &acing their o)n mortality* .ne need that all o& my clients )ill share is the need &or ade/uate, /uality sleep* (y goal in researching insomnia and depression )as to learn )hat researchers ha%e &ound regarding the need &or sleep* I e,amined the normal sleep cycle and discussed the nature o& insomnia* I also descri+ed the correlations +et)een insomnia and depression to gain a +etter understanding o& the relationship +et)een the t)o* 0inally, I e,amined the most prominent treatment options &or +oth insomnia and depression so that I )ill +e +etter prepared to treat my clients*

The Sleep Cycle !+stract Se%eral disciplines ha%e contri+uted to our )or#ing understanding o& sleep* !s researchers in this &ield, psychologists are typically most interested in studying sleep distur+ances* .ne o& the most pre%alent o& these distur+ances is insomnia, a condition that is o&ten accompanied +y other psychological pro+lems, including depression* ! thorough re%ie) o& the e,isting literature )ill pro%ide the +asis &or conclusions regarding the relationship +et)een insomnia and depression* Speci&ically, this paper )ill address the connections among the human sleep cycle, insomnia, depression, and success&ul methods o& treating patients )ith +oth insomnia and depression*

The Sleep Cycle Ta+le o& Contents Personal Rele%ance Pre&ace*************************************1 !+stract*******************************************************2 Ta+le o& Contents**********************************************3 Physiology o& Sleep********************************************4 Human "iological Cloc#************************************5 Stages o& Sleep Cycle*************************************6 Insomnia*******************************************************7 Classi&ication*******************************************'' E&&ects o& Sleep Clinical epri%ation*****************************'1

iagnosis***************************************'2 epression and Insomnia******************'3

Relationship +et)een

The Role o& Serotonin************************************'4 Cause and E&&ect Relationship****************************'4 8ia+le Treatment .ptions**************************************'6 Conclusion****************************************************'7 Re&erences****************************************************1'

The Sleep Cycle The Sleep Cycle: Normalcy, Insomnia, and its Relationship to epression

Sleep is a +iological need shared +y all humans, yet it is only %aguely understood +y researchers* 9e do #no) that healthy sleep patterns are related to other signs o& physical and mental )ellness* Con%ersely, pro+lems sleeping are symptomatic o& other health ris#s* In e,treme cases, disordered sleep can +e attri+uted as the cause o& other serious disorders* It can lead to disastrous accidents* There&ore, the importance o& sleep, and o& understanding sleep, is %ital* Physiology of Sleep The theory o& sleep as a +iological process is relati%ely ne), dating +ac# to the '74:;s )hen RE( sleep )as &irst disco%ered <!serins#y = >leitman, '742?* $ntil that time, there )ere a couple o& central misconceptions regarding the sleep@)a#e cycle* Sleep )as commonly thought to +e a mechanism through )hich the +ody compensated &or a daily +uild@up o& hypnoto,ins* ! person )as thought to &all asleep )hen the le%el o& hypnoto,ins in the +lood +ecame too high* The person )ould then a)a#en )hen these to,ins )ere e,pelled* ! second pro+lem )ith early sleep research )as the &aulty notion that the sleep@)a#e cycle )as not endogenous* That is, some researchers attri+uted the sleep@)a#e cycle to en%ironmental &actors that acted upon a person rather than a person;s intrinsic +iological rhythm* They

The Sleep Cycle thought that &actors such as le%els o& light caused the cycle to occur, )hen in reality this is not the case <La%ie, 1::'?* The cycle persists e%en )hen e,ternal cues are eliminated <9eiten, 1::3?* 9hen !serins#y and >leitman <'742? disco%ered RE( sleep, scienti&ic studies o& sleep +ecame more common* Still, it )as not until the '7A:;s that sleep researchers +egan to &ocus on the sleep@cycle, its causes, and dreaming <La%ie, 1::'?* Today, researchers ha%e adopted a perspecti%e that is similar to the %ie) o& early researchers* !lthough the notion o& hypnoto,ins has +een a+andoned, it is still thought that )a#e&ulness o%er a period o& time causes the +ody to de%elop a Bsleep de+tC )hich can +e paid through sleep <Espie, 1::1?* Human Biological Clock The sleep@)a#e cycle is a type o& circadian rhythm, )hich is a +iological cycle that repeats itsel& appro,imately e%ery 13 hours <La%ie, 1::'?* Physiologists ha%e identi&ied a net)or# o& structures and chemicals in the +rain )hich control the sleep@ )a#e rhythm* Collecti%ely, this net)or# ser%es the &unction o& the human +iological cloc#* The suprachiasmatic nucleus <SPN? is a small structure in the hypothalamus and is the central pacema#er o& the +ody* Lesions o& the area o& the +rain disrupt circadian rhythms, demonstrating the great importance o& this area in the

The Sleep Cycle regulation o& the sleep@)a#e cycle <L* "ec#er, personal communication, (arch ', 1::3?* 9hen certain retinal receptors are e,posed to light, they send in&ormation to the SPN* The SPN sends input to the pineal gland, )hich is responsi+le &or the secretion o& a hormone called melatonin* Secretion o& melatonin &rom the pineal gland helps to resynchroniDe the +ody;s +iological cloc# <9eiten, 1::3?* (elatonin is produced only at nightE light inhi+its its synthesis <La%ie, 1::'?* Stages of Sleep Cycle 9hen the rhythm is properly synchroniDed, an indi%idual )ill cycle through se%eral hours o& )a#e&ulness &ollo)ed +y a

period o& sleep* The sleep cycle can +e di%ided into &i%e stages* Non-REM sleep* The &irst &our stages o& sleep are categoriDed together as non@RE( sleep +ecause there are no rapid eye mo%ements during these stages* Non@RE( sleep is also characteriDed +y %arying degrees o& +rain acti%ity, )hich is measured +y an electroencephalograph <EEF?* Stage one is a +rie& transitional period o& light sleep* uring this stage, +reathing

and heart rate +egin to slo)* "ody temperature decreases and muscles +egin to rela,* Theta )a%es are prominent in the +rain during this stage* 9hile the amount o& time it ta#es to &all asleep %aries &rom person to person, most people spend '@6 minutes in the &irst stage o& sleep* Stage t)o &ollo)s and is characteriDed +y sleep spindles, )hich are +rie& +ursts o&

The Sleep Cycle higher &re/uency )a%es* EEF studies re%eal mi,ed +rain acti%ity during stage t)o sleep, )hich lasts appro,imately ':@14 minutes <9eiten, 1::3?* 0inally, a+out 2: minutes a&ter &alling asleep, indi%iduals reach slo) )a%e sleep, )hich is comprised o& stages three and &our* Slo) )a%e sleep recei%es its name &rom the high amplitude, lo) &re/uency delta )a%es that are present during sleep stages three and &our* Sleep is deeper in stages three and &our than in the &irst t)o stages* ! person )ill remain in slo) )a%e sleep &or a+out 2: minutes +e&ore cycling +ac# through the lighter stages o& sleep and &inally into RE( sleep <9eiten, 1::3?* REM sleep* RE( sleep is some)hat mysterious* uring RE(

sleep, the +rain demonstrates high &re/uency +eta )a%es that mimic )a#e&ulness* "lood pressure rises and respiration increases* !nother characteristic o& this stage o& sleep is the presence o& rapid eye mo%ements, )hich is ho) RE( sleep got its name* In spite o& the apparent +urst o& acti%ity during this phase, indi%iduals are actually in a deep sleep* Their muscles are %ery rela,ed and they are di&&icult to a)a#en* The +eta )a%es and eye mo%ements, there&ore, are attri+uted to the process o& dreaming* Indeed, most dreaming does occur during RE( sleep, although it is possi+le to dream in non@RE( sleep as )ell <9eiten, 1::3?*

The Sleep Cycle Variations in the cycle* Slo) )a%e sleep is most prominent early in the night* Indi%iduals )ill spend gradually less time in slo) )a%e sleep and more time in RE( sleep as they cycle through the sleep stages* The &irst RE( period during the night lasts only a &e) minutes, )hile the last one or t)o periods may last up to an hour <9eiten, 1::3?* The sleep@)a#e cycle %aries signi&icantly )ith age* Young adults spend a+out 1:G o& their total sleep time in slo) )a%e sleep and 1:G in RE( sleep, suggesting that &luctuations in slo) )a%e and RE( duration e%en themsel%es out during the night* Ho)e%er, this is not true o& other age groups* In&ants spend a great deal more time in RE( sleep than adults* In addition, older adults spend dramatically less time in slo) )a%e sleep than younger adults <9eiten, 1::3?* There is also a decrease in total time spent sleeping in the elderly, despite an increase in the amount o& time spent in +ed <(orin = Framling, '7A7?* Clearly, the sleep@)a#e cycle has %ariations according to indi%idual di&&erences* Stimuli outside the indi%idual also ha%e the potential to disrupt the rhythm* These &actors include periods o& stress, illness, or mental dys&unction* 9hen the sleep@)a#e cycle +ecomes irregular, sleep may +ecome distur+ed* Insomnia Insomnia, the most reported o& all sleep distur+ances <Ruya#, "ils+ury, = Ra-da, 1::3?, a&&ects millions o& people in

The Sleep Cycle the $nited States each year* Estimates o& its pre%alence %ary )idely* Some sur%ey studies indicate complaints o& insomnia in

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2:@34G o& adults* Primary insomnia occurs in '@':G o& adults and accounts &or '4@14G o& cases o& chronic insomnia <!merican Psychiatric !ssociation, 1:::?* Insomnia is more common in )omen than in men <Pallesen, Nordhus, Ha%i#, = Nielsen, 1::'?* !s noted pre%iously, the elderly are at greater ris# &or de%eloping insomnia than younger adults <(orin = Framling, '7A7?* ! pro+lem )ith the epidemiological data is that some people )ho report su+-ecti%e insomnia ha%e no o+-ecti%e sleep de&iciencyE con%ersely, people )ho report themsel%es as normal sleepers may demonstrate signi&icant sleep distur+ances* These people may not +e a)are o& the distur+ance +ecause it produces no detriments to daytime &unctioning, or they may simply choose not to report it <Edinger, 0ins et al*, 1:::?* Ne%ertheless, the pre%alence o& insomnia is great enough to merit &urther in%estigation* Ho)e%er, +e&ore proceeding )ith a more detailed description o& insomnia, it should +e noted that sleep needs %ary dramatically among indi%iduals* Research tells us that the a%erage adult needs 6@A hours o& sleep a night* Still, )e must ta#e this &igure &or -ust )hat it is: a statistical a%erage )ith de%iations in each direction* (any adults can &unction normally on less than se%en hours o& sleep* .thers may need more than

The Sleep Cycle eight hours a night to &eel ade/uately rested* The important thing to remem+er is that insomnia is not strictly de&ined according to the num+er o& hours a person sleeps each night <Espie, 1::1?* Classification Insomnia can +e su+di%ided into categories according to either <'? the cause o& the insomnia or <1? the characteristics

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o& the sleep distur+ance* In the &irst case, insomnia is di%ided into primary insomnia and secondary insomnia* Primary insomnia re&ers to insomnia that is caused +y a psychological disorder, such as conditioned arousal to the +edroom* Secondary insomnia re&ers to insomnia )ith a medical or psychiatric +asis* 0or e,ample, a patient su&&ering &rom se%ere pain )ould li#ely e,perience sleep loss* In this case the distur+ance in sleep )ould +e la+eled secondary insomnia* The remainder o& this paper )ill &ocus on primary insomnia, as most research &ocuses on this type o& insomnia <Lichstein, urrence, Riedel, = "ayen, 1::'?

and it is the type o& insomnia most related to the &ield o& psychology* The iagnostic an! Statistical Manual of Mental isor!ers,

a pu+lication +y the !merican Psychiatric !ssociation <1:::?, de&ines primary insomnia as: a complaint o& di&&iculty initiating or maintaining sleep or o& nonrestorati%e sleep that lasts &or at least ' month

The Sleep Cycle

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<Criterion !? and causes clinically signi&icant distress or impairment in social, occupational, or other important areas o& &unctioning <Criterion "?* The distur+ance in sleep does not occur e,clusi%ely during the course o& another sleep disorder <Criterion C? or mental disorder <Criterion ? and is not due to the direct physiological

e&&ects o& a su+stance or a general medical condition <Criterion E?* <p* 477? Primary insomnia can +e &urther characteriDed according to the onset and duration o& the sleep distur+ance* This method o& classi&ication produces &our types o& insomnia* Sleep onset insomnia in%ol%es di&&iculty &alling asleep* Sleep maintenance insomnia is characteriDed +y di&&iculty &alling +ac# to sleep a&ter )a#ing during the night* Terminal insomnia is similar to sleep maintenance insomnia e,cept the patient does not return to sleep &or e%en a short time a&ter )a#ing during the night or early morning* 0inally, nonrestorati%e sleep is characteriDed +y &eeling unre&reshed a&ter sleep <Pallesen et al*, 1::'?* Effects of Sleep epri"ation

People )ho su&&er &rom insomnia report a %ariety o& detrimental e&&ects, the most common +eing decreased daytime &unctioning* Chronic insomniacs report more memory di&&iculties, increased )or# a+senteeism, and &e)er promotions at )or# than do their co)or#ers )ho recei%e ade/uate rest* 0urther, insomnia has

The Sleep Cycle detrimental e&&ects on society as a )hole, including loss o&

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producti%ity, increased occurrence o& accidents, and e%en rising costs o& healthcare <Ruya#, "ils+ury, = Ra-da 1::3?* ! recent report +y Harrison and Horne <1:::? e,amined the e&&ects o& sleep loss on the decision@ma#ing process* The authors list se%eral pro+lem areas &or sleep@depri%ed decision ma#ers, including: impaired language s#ills communication, lac# o& inno%ation, in&le,i+ility o& thought processes, inappropriate attention to peripheral concerns or distraction, o%er@reliance on pre%ious strategies, un)illingness to try out no%el strategies, unrelia+le memory &or )hen e%ents occurred, change in mood including loss o& empathy )ith colleagues, and ina+ility to deal )ith surprise and the une,pected* <p* 135? These results, though not surprising, are cause &or concern* Indeed, Harrison and Horne <1:::? mention the connection +et)een sleep depri%ation and disasters such as the e,plosion o& the Challenger space shuttle* Pre%ention o& serious accidents li#e this may +egin )ith a +etter understanding o& the e&&ects o& sleep depri%ation* Clinical iagnosis SM-IV-#R de&inition o&

Con&usion may arise )hen the

primary insomnia is compared )ith researchers; reports o& it* !s

The Sleep Cycle mentioned, Lichstein et al* <1::'? listed psychological distur+ance as the cause o& primary insomnia* This statement should not +e considered contradictory to the criteria &or diagnosis listed in the SM-IV-#R <!merican Psychiatric

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!ssociation, 1:::? )hich state that the diagnosis o& primary insomnia must not +e made i& the distur+ance occurs e,clusi%ely )ith a mental disorder* 0or e,ample, a patient )ho su&&ers &rom depression may spend a great amount o& time in +ed, yet e,perience di&&iculty sleeping* E%entually, the patient +ecomes negati%ely conditioned &or sleep and may e,perience insomnia e%en a&ter the depression has +een resol%ed* !ccording to the SM-IV-#R, this situation

)ould +e grounds &or a diagnosis o& primary insomnia +ecause the patient e,hi+its insomnia that stems &rom a psychological disorder +ut does not occur e,clusi%ely )ith the psychological disorder <!merican Psychiatric !ssociation, 1:::?* The relationship +et)een insomnia and depression )ill no) +e addressed in greater detail* Relationship $et%een epression an! Insomnia

Researchers, clinicians, and e%en patients ha%e all identi&ied sleeping disorders )ith depression &or many years* irect correlations +et)een sel&@reports o& sleep di&&iculty and le%els o& an,iety and depression are commonly reported in the literature <Edinger, 0ins et al*, 1:::?* Ho)e%er, this

The Sleep Cycle correlation does not gi%e us any insight into the cause@e&&ect

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relationship <i& any e,ists? +et)een insomnia and depression* To de%elop a +etter understanding o& this relationship, a comparison )ill &irst +e made +et)een depression and insomnia at the physiological le%el* #he Role of Serotonin Serotonin is a neurochemical that is #no)n to +e associated )ith depression* Research indicates that patients )ith depression &re/uently ha%e lo)er le%els o& serotonin in the +rain than nondepressi%es* Common antidepressant medications include a &amily o& selecti%e serotonin reupta#e inhi+itors, or SSRIs <"uysse, 1::3?, designed to e,tend the amount o& time that serotonin is present in synaptic cle&ts in the +rain* The medications success&ully reduce or eliminate depressi%e symptoms &or many patients* Ho)e%er, SSRIs ha%e mi,ed e&&ects on sleeping patterns* They can cause insomnia in some patients, )hile inducing dro)siness in others <"uysse, 1::3?* 9hen SSRIs are discontinued, either gradually or a+ruptly, insomnia can result <Ri%as@8aD/ueD, Hohnson, "lais, = Rey, '777?* These e&&ects may +e attri+uted to serotonin;s role in the regulation o& RE( sleep <L* "ec#er, personal communication, (arch ', 1::3?* Cause an! Effect Relationship

The Sleep Cycle (any studies ha%e &ound a direct correlation +et)een

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depression and some type o& sleep distur+ance* !llgo)er, 9ardle, and Steptoe <1::'? &ound that 16G o& sur%ey respondents )ho met criteria &or depressi%e symptoms also reported irregular sleep hours <less than se%en or more than 7 hours o& sleep each night?* (onroe, Thase, and Simons <'771? reported similar &indings* Sel&@reports o& depressi%e symptoms and stress )ere directly correlated to RE( sleep latency* .&ten, these correlations are e,plained +y listing the sleep distur+ance among the symptoms o& depression* In &act, clinicians, researchers, and e%en patients themsel%es o&ten %ie) pro+lems sleeping as simply e,tensions o& depression <>ra#o) et al*, 1:::?* .ther studies indicate that symptoms o& insomnia are more li#ely to +e o+ser%ed +y clinicians in patients )ho report themsel%es as depressed, +ut lac# a clinical diagnosis o& depression than in patients )ho are clinically depressed <Santor = Coyne, 1::'?* ! study on the relationships o& light, insomnia, and depression &ound that greater illumination during the day )as negati%ely correlated )ith +oth sleep latency and depressed mood <9allace@Fuy et al*, 1::1?* The results o& these t)o studies demonstrate the close and comple, relationship +et)een insomnia and depression*

The Sleep Cycle .ne study <"uch)ald = Rudic#@ a%is, '772? &ound that sleep distur+ance )as reported in 7AG o& patients in a ma-or depressi%e episode* 0urther, 73G o& the control group reported no sleep distur+ance, suggesting not only that distur+ed sleep is a symptom o& depression, +ut it may also +e use&ul in

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predicting a &uture diagnosis o& depression* !nother study &ound that insomnia may result in su+se/uent mood dys&unction <Nicassio = 9allston, '771?* These mi,ed results indicate that la+eling insomnia as a symptom o& depression may +e hasty* (ost o& the e,isting data comparing insomnia and depression is correlationalE there&ore, causation o& one +y the other cannot +e ade/uately determined* There are a &e) studies <Nicassio = 9allston, '771? )hich attempt to address a causal relationship +et)een the t)o, +ut they are limited in their scope and applica+ility* 0urther research is needed to de%elop a causal lin#* In addition, researchers should try to e,plain )hat must occur in order &or depression to lead to insomnia, or %ice %ersa* 9hy does it seem that in some cases, insomnia results &rom depression, +ut in other cases the re%erse is trueI This /uestion must +e addressed so that treatment can +e more success&ul* Via$le #reatment &ptions E%en though a concrete causal relationship is lac#ing, insomnia and depression can o&ten +e treated at the same time

The Sleep Cycle through the same types o& therapies* Cogniti%e@+eha%ioral therapy <C"T? is a popular approach &or the treatment o& +oth depression and insomnia* C"T has +een &ound to reduce sleep %aria+ility, )hich may pro%ide indi%iduals )ith more satis&action &rom their sleep <Edinger, Hoelscher, (arsh, Lipper, = Ionescu@Pioggia, '771?* In a study +y Espie, Inglis, and Har%ey <1::'?, insomnia patients )ere e,posed to 5 )ee#ly group sessions o& C"T* Participants also completed a one@year &ollo)@up to trac# the e&&ecti%eness o& the therapy* Results indicated that &or t)o@thirds o& the patients, C"T led to normaliDation o& sleep onset latency and time spent a)a#e at night* These results do not indicate C"T as a cure@all method &or alle%iating insomnia* Ho)e%er, the results are encouraging gi%en that these patients )ere su&&ering &rom signi&icant sleep distur+ances and &ollo)ing treatment )ere approaching normal sleeping patterns* Espie, Inglis, and Har%ey <1::'? also had an interesting &inding regarding patients )ith high le%els o& an,iety and depressi%eness* 9hile it is noted that patients )ith depressi%e illness )ere e,cluded &rom the study, those patients )ho )ere ele%ated in depressi%eness and an,iety +ut short o& clinical diagnosis e,perienced greater response to C"T than patients )ho )ere not ele%ated on these measures* In particular, ele%ated patients e,perienced more impro%ements in continuity o& their

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The Sleep Cycle

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sleep* This &inding is puDDling +ecause it seems to suggest that insomniacs )ill respond +etter to this &orm o& treatment i& they also su&&er &rom dys&unctions in mood* Yet, )hy should this +e the caseI !gain, &urther research must +e done to address the comple, relationship to ans)er this /uestion* C"T need not +e completed &ace to &ace to +e success&ul* ! recent study indicated that telephone consultations )ere as success&ul as +oth indi%idual and group &ace@to@&ace sessions in treating insomniacs <"astien, (orin, .uellet, "lais, = "ouchard, 1::3?* ! pioneering study o& internet@+ased sel&@help therapy sho)s promise in pro%iding a lo)er@cost alternati%e to indi%idual therapy <Strom, Pettersson, = !ndersson, 1::3?* In spite o& success rates o& psychological therapies, the most common treatment o& +oth insomnia and depression is medication* Pharmacology pro%ides a simple and cost e&&ecti%e means o& treatment, +ut users o& insomnia medications ris# tolerance and dependence o%er time <"astien et al*, 1::3?* 9ithdra)al e&&ects can +ring on re+ound insomnia* Perhaps more importantly, use o& sedati%e medication can lead to decreased daytime &unctioning, )hich is one o& the primary di&&iculties o& insomnia in the &irst place <(urtagh = Freen)ood, '774?* Conclusion In order to understand a dys&unction o& a gi%en system, one must &irst understand the normal &unctioning o& that system*

The Sleep Cycle There&ore, a re%ie) o& the sleep@)a#e cycle is necessary )hen e,amining the cycle;s most prominent dys&unction: insomnia* The pre%alence o& insomnia is great enough to )arrant in%estigation o& the )ays it de%elops*

1:

! diagnosis o& insomnia is o&ten made in con-unction )ith a diagnosis o& depression* These disorders are intricately related* The relationship is comple, enough to ha%e a%oided causal e,planation +y researchers* Ho)e%er, )ith e%ery study conducted, )e are one step closer to unra%eling the connection* espite the tendency to %ie) insomnia as merely a result o& depression in depressed patients, clinicians should e,amine each case care&ully +e&ore determining any cause@e&&ect relationship* Studies indicate that depression o&ten leads to insomnia and other sleep disorders* Ho)e%er, in some cases, insomnia can +e the cause o& depression and other disorders* This distinction must +e made in order to ensure proper treatment o& each disorder* 9hile medication remains the most popular treatment choice, C"T can +e a success&ul and cost e&&ecti%e alternati%e*

The Sleep Cycle Re&erences !llgo)er, !*, 9ardle, H*, = Steptoe, !* <1::'?* epressi%e

1'

symptoms, social support, and personal health +eha%iors in young men and )omen* Health Psychology' ()' 112@116* J!merican Psychiatric !ssociation* <1:::?* iagnostic an!

statistical manual of mental !isor!ers <te,t re%ision?* 9ashington, C: !uthor*

J!serins#y, E*, = >leitman, N* <'742?* Regularly occurring periods o& eye motility, and concomitant phenomena, during sleep* Science' **+' 162@163* "astien, C* H*, (orin, C* (*, .uellet, (*, "lais, 0* C*, = "ouchard S* <1::3?* Cogniti%e@+eha%ioral therapy &or insomnia: Comparison o& indi%idual therapy, group therapy, and telephone consultations* ,ournal of Consulting an! Clinical Psychology' -(' 542@547* "uch)ald, !* (*, = Rudic#@ a%is, * <'772?* The symptoms o&

ma-or depression* ,ournal of .$normal Psychology' *)(' '76@ 1:4* "uysse, * H* <1::3?* Insomnia, depression, and aging: !ssessing

sleep and mood interactions in older adults* /eriatrics' 01' 36@4'* Edinger, H* *, 0ins, !* I*, Flenn, * (*, Sulli%an, R* H*,

"astian, L* !*, (arsh, F* R*, et al* <1:::?* Insomnia and the eye o& the +eholder: !re there clinical mar#ers o&

The Sleep Cycle o+-ecti%e sleep distur+ances among adults )ith and )ithout insomnia complaintsI ,ournal of Consulting an! Clinical Psychology' 2+' 4A5@472* Edinger, H* *, Hoelscher, T* H*, (arsh, F* R*, Lipper, S*, =

11

Ionescu@Pioggia, (* <'771?* ! cogniti%e@+eha%ioral therapy &or sleep@maintenance insomnia in older adults* Psychology an! .ging' -' 1A1@1A7* Espie, C* !* <1::1?* Insomnia: Conceptual issues in the de%elopment, persistence, and treatment o& sleep disorders in adults* .nnual Re"ie% of Psychology' 03' 1'4@132* Espie, C* !*, Inglis, S* H*, = Har%ey, L* <1::'?* Predicting clinically signi&icant response to cogniti%e +eha%ior therapy &or chronic insomnia in general medical practice: !nalyses o& outcome data at '1 months posttreatment* ,ournal of Consulting an! Clinical Psychology' 21' 4A@55* Harrison, Y*, = Horne, H* !* <1:::?* The impact o& sleep depri%ation on decision ma#ing: ! re%ie)* ,ournal of E4perimental Psychology5 .pplie!' 2' 125@137* >ra#o), "*, !rtar, !*, 9arner, T* *, (elendreD, *, Hohnston,

L*, Holli&ield, (*, Fermain, !*, = >oss, (* <1:::?* Sleep disorder, depression, and suicidality in &emale se,ual assault sur%i%ors* Crisis5 #he ,ournal of Crisis Inter"ention an! Suici!e Pre"ention' (*' '52@'6:* La%ie, P* <1::'?* Sleep@)a#e as a +iological rhythm* .nnual

The Sleep Cycle Re"ie% of Psychology' 0(' 166@2:2* Lichstein, >* L*, urrence, H* H*, Riedel, "* 9*, "ayen, $* H*

12

<1::'?* Primary %ersus secondary insomnia in older adults: Su+-ecti%e sleep and daytime &unctioning* Psychology an! .ging' *2' 153@16'* (onroe, S* (*, Thase, (* E*, = Simons, !* * <'771?* Social

&actors and the psycho+iology o& depression: Relations +et)een li&e stress and rapid eye mo%ement sleep latency* ,ournal of .$normal Psychology' *)*' 41A@426* (orin, C* (*, = Framling, S* E* <'7A7?* Sleep patterns and aging: Comparison o& older adults )ith and )ithout insomnia complaints* Psychology an! .ging' 6' 17:@173* (urtagh, * R* R*, = Freen)ood, >* (* <'774?* Identi&ying

e&&ecti%e psychological treatments &or insomnia: ! meta@ analysis* ,ournal of Consulting an! Clinical Psychology' 23' 67@A7* Nicassio, P* (*, = 9allston, >* !* <'771?* Longitudinal relationships among pain, sleep pro+lems, and depression in rheumatoid arthritis* ,ournal of .$normal Psychology' *)*' 4'3@41:* Pallesen, S*, Nordhus, I* H*, Ha%i#, .*, = Nielsen, F* H* <1::'?* Clinical assessment and treatment o& insomnia* Professional Psychology5 Research an! Practice' 3(' ''4@'13* Ri%as@8aD/ueD, R* !*, Hohnson, S* L*, "lais, (* !*, = Rey, F* H*

The Sleep Cycle <'777?* Selecti%e serotonin reupta#e inhi+itor discontinuation syndrome: $nderstanding, recognition, and management &or psychologists* Professional Psychology5 Research an! Practice' 3)' 353@357* Ruya#, P* S*, "ils+ury, C* *, Ra-da, (* <1::3?* ! sur%ey o&

13

insomnia treatment at Canadian sleep centers: Is there a role &or clinical psychologistsI Cana!ian Psychology' 60' '54@'62* Santor, * !*, = Coyne, H* C* <1::'?* E%aluating the continuity

o& symptomatology +et)een depressed and nondepressed indi%iduals* ,ournal of .$normal Psychology' **)' 1'5@114* Strom, L*, Pettersson, R*, = !ndersson, F* <1::3?* Internet@ +ased treatment &or insomnia: ! controlled e%aluation* ,ournal of Consulting an! Clinical Psychology' -(' ''2@'1:* 9allace@Fuy, F* (*, >rip#e, * 0*, Hean@Louis, F*, Langer, R*

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Note: !n J indicates that paper copies o& sources are located in the port&olio* !ll other sources can +e &ound on the enclosed C *